A nurse is assisting with the ambulation of a client with the use of a gait belt, who becomes light-headed and begins to fall. Which of the following actions should the nurse take?

extend one leg and allow the client to slide down the leg to the floor.

move both feet together when the client begins to fall

wrap both arms around the client's arm and shoulders

protect the client's extremities while lowering them to the floor.

Answer and Explanation

The Correct Answer is A

A. Extend one leg and allow the client to slide down the leg to the floor.

It helps to control the fall, protects the client from injury, and allows the nurse to safely guide the client to the floor without using excessive force.

B. Move both feet together when the client begins to fall.

Keeping the feet together reduces stability and increases the risk of both the client and nurse falling.

C. Wrap both arms around the client's arm and shoulders.

This could cause injury to the client’s upper body and doesn't provide support for a safe fall.

D. Protect the client's extremities while lowering them to the floor.

While protecting extremities is important, the nurse’s primary action should be to use proper body mechanics (like extending one leg) to safely lower the client.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Hold the crutches on your unaffected side when preparing to sit in a chair

This helps maintain balance and control while transitioning from standing to sitting.

B. Hold the crutches 9 inches in front and to the side of each foot

The correct placement is approximately 6 inches (not 9) in front and 6 inches to the side of each foot for stability.

C. Lean on the crutches to support your body weight when standing

Weight should be supported by the hands on the handgrips, not the axillae, to avoid nerve injury (e.g., brachial plexus damage).

D. Fully extend your arms when holding onto the hand grips

The elbows should be slightly flexed (about 20-30 degrees) to allow proper support and shock absorption.

A. Elevate the foot. B. Encourage range-of-motion exercises of the foot. C. Provide the client with a light snack. D. Apply a compression bandage. E. Apply ice to the ankle.

Correct Answer is ["A","C","D","E"]

Explanation

A. Elevate the foot:

Elevation helps reduce swelling by promoting venous return.

B. Encourage range-of-motion exercises of the foot:

Movement should be limited until the injury is evaluated to prevent further damage.

C. Provide the client with a light snack:

This can be appropriate if there are no contraindications, especially if the client has been waiting and is hungry. It doesn’t worsen the injury and supports comfort.

D. Apply a compression bandage:

Compression helps reduce swelling and provides support to the injured joint.

E. Apply ice to the ankle:

Ice reduces inflammation and helps with pain management during the acute phase of a soft-tissue injury.

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A nurse is assisting with the ambulation of a client with the use of a gait belt, who becomes light-headed and begins to fall. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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